Improving hepatitis B screening prior to rituximab at a multispecialty urban hospital.

Abstract

176 Background: Rituximab(R) is a novel anti-CD20 monoclonal antibody used in multiple hematologic and rheumatologic diseases. Patients who are hepatitis B surface antigen (HBsAg) or hepatitis B core antibody (HBcAb) positive are at risk for hepatitis-B reactivation with R-based treatments. Therefore, the VA’s medication use evaluation tracker recommends serological testing for HBsAg, HBsAb and HBcAb within 6 months prior to initiating R. We conducted a PDSA cycle to improve Hepatitis-B serological testing in patients receiving R at Birmingham VA medical center (BVAMC). Methods: For baseline evaluation, patients at BVAMC who were treated with R between 2004- march 2014 were retrospectively evaluated for HBV serology results 6 months prior to first treatment. Presence of all 4- HBsAg, HBsAb and HBcAb (IgM and total) was complete; absence of all 4 was ‘not done’ with remaining being incomplete. After conducting a RCA, 3 pharmacy-based interventions were implemented- 1) pharmacy education; 2) pharmacist autonomy to order hepatitis B serology eliminating physician dependence; 3) pharmacy reminders to health care providers to order HBV serology. We aimed to improve ‘complete’ screening rates to > 90% in the post-intervention period (april 2014-sep 2016). Results: In the pre-intervention group (n = 162), majority (81%) had hematologic indications and complete testing was performed in 38%, reminder being incomplete (13%) or not done (49%). Post-intervention (n = 86), majority (54%) had rheumatologic indications with complete testing in 71%, incomplete in 15% and not done in 14%. No Hepatitis B reactivations were identified in either study periods. Conclusions: Pre-intervention, ‘complete’ testing was performed in only one-third of patients and our intervention was effective in almost doubling screening rates. We also demonstrate increasing use of Rituximab in non-hematologic conditions and with second-generation anti-CD20 Ofatumumab and Obinutuzumab also requiring similar testing; our study could standardize Hep-B screening for these agents. A second PDSA cycle with a reflex ‘forcing-function’ EMR-based tool to decrease reliance on human factors is planned to meet the study goal of > 90%.